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FAMILY COUNSELING FORM

Child's First Name

Child's Last Name

Child's Birthday

Age

Family Information

Address (Include: City, State, & Zip)

Father's Name

Mother's Name

Siblings Name

AGE

Siblings Name

AGE

Siblings Name

AGE

Siblings Name

AGE

Who else lives in the home? (please include name & relationship to child):

Are there any close family members not living in the home?

YES

NO

Adopted?

YES

NO

Who?

If so, at what age?

Explain who the child has lived with since birth?

Behavior Concerns

What concerns or issues convinced you to seek assistance now?

HOME behavioral concerns:

SCHOOL behavioral concerns:

When did you start noticing these behavioral concerns?

Current or past stressors that may be contributing to my child’s problems:

Mental health diagnosis and when they are diagnosed:

Is there a history of, or current concern with any of the following? If so, how long have these been problems?

School behavioral problems

Stealing

High temperatures

Academic/special education

Speech difficulties

Runaway

Eating Problems

Masturbation

Head injuries/concussions

Temper tantrums

Wetting Pants

Coordination

Avoids cuddling

Poor Attention

Constipation

Frequent bad dreams

Legal Problems

Fears

Bizarre Behaviors

Poor memory

Cruel to animals

Lying

Impulsivity

High energy

Fire Setting

Aggressive behavior

Obsessive behavior

Attention Deficit Disorder

Crying spells

Soiling pants

Truancy

Headaches

Bed wetting

Sex play with other children

Defiance to authority

Suicidal thoughts

Hallucinations

Other

How does your child get along with other children at home and/or school?

What are your concerns about your child’s friends?

Describe relationship between your child and the following people:

Mother

Father

Siblings

What are your child’s strengths?

Treatment (Current and Previous)

Individual Therapy

YES

NO

DATES

With Who?

Results

Individual Therapy

YES

NO

DATES

With Who?

Results

Individual Therapy

YES

NO

DATES

With Who?

Results

Family Therapy

YES

NO

DATES

With Who?

Results

Family Therapy

YES

NO

DATES

With Who?

Results

Intensive Outpatient Programs (IOP)

YES

NO

DATES

Where?

Results

Partial Hospitalization Program (PHP)

YES

NO

DATES

Where?

Results

Impatient

YES

NO

DATES

Where?

Results

Impatient

YES

NO

DATES

Where?

Results

Family History

Is there a family history of mental illness in your family?

YES

NO

Please specify if yes:

Is there a family history of substance abuse in your family?

YES

NO

Please specify if yes:

Pregnancy History/ Mother

While pregnant with this child was the mother under a doctor’s care?

YES

NO

During pregnancy, did the mother:

Take any medications?

YES

NO

Please List

Drug Use?

YES

NO

How Much?

During the pregnancy were there any complications?

Length of pregnancy:

Bottle-fed:

Breast-fed:

Age Weaned

Mother’s health during pregnancy:

Good

Fair

Poor

If Fair or Poor please explain

Drink alcohol?

YES

NO

How Much?

Smoke?

YES

NO

What/How Much?

Mother’s health during pregnancy:

Normal

Breach

Cesarean

Problems after delivery?

Birth weight:

DEVELOPMENTAL HISTORY

As well as you can remember, where there any delays in the follow areas?

As well as you can remember, where there any developmental delays such as walking, talking, toilet trained, etc?

Any speech/language problems?

Any sleep problems?

MEDICAL HISTORY

Please list any CURRENT or PAST medical or neurological problems:

Hospitalization

YES

NO

Select a date

Primary Care Doctor:

Child Height:

Medications

Weight:

Name:

Dosage:

Reason:

Name:

Dosage:

Reason:

Name:

Dosage:

Reason:

Name:

Dosage:

Reason:

Last Physical:

Allergies:

How long has your child been on it?

Results:

How long has your child been on it?

Results:

How long has your child been on it?

Results:

How long has your child been on it?

Results:

Name of doctor/psychiatrist who prescribed medications:

History Substance Use

(please indicate if currently using)

Vaping

YES

NO

Marijuana

YES

NO

Other Drugs

YES

NO

Alcohol

YES

NO

Tobacco

YES

NO

Prescription Pills

YES

NO

Please indicate if there is any current substance use.

History of Abuse

Emotional

YES

NO

Physical

YES

NO

Sexual

YES

NO

If so, explain including dates:

History of Trauma

Close Death

YES

NO

Natural Disaster

YES

NO

Divorce

YES

NO

Move

YES

NO

Accident

YES

NO

Crime

YES

NO

Other:

Suicidal / Self Harm

Suicidal Thoughts

Suicide Attempt

Current

YES

NO

Current

YES

NO

When:

Self Harm

Current

YES

NO

Past

YES

NO

Past

YES

NO

Plan:

Past

YES

NO

Method:

Frequency:

Spiritual

Home Church

Where are you, as a family, spiritually?

Goals:

What are your expectations/goals for your daughter while being in our program?

What are your expectations/goals for yourselves as parents while your daughter is in our program?

Your Signature

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Contact Us

Phone: 913-262-8885

Fax: 913-362-0505

Mail Address:

7040 Antioch Road

Overland Park, KS 66204

How Can We Help?

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